Healthcare Provider Details

I. General information

NPI: 1669396735
Provider Name (Legal Business Name): JESSE STEPHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 CHESTNUT ST
GRAND FORKS ND
58201-8020
US

IV. Provider business mailing address

5100 CHESTNUT ST
GRAND FORKS ND
58201-8020
US

V. Phone/Fax

Practice location:
  • Phone: 701-741-2720
  • Fax:
Mailing address:
  • Phone: 701-741-2720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: